Project Summary Tracheal intubation (TI) is the most commonly performed invasive procedure in neonatal intensive care units (NICUs). Neonatal TIs have unique risks related to anatomy and physiology. Adverse TI associated events and severe desaturation (low oxygen level) are reported at a surprisingly high rate in limited literature from a single center including our preliminary report. However, multi-center epidemiology and the magnitude of this safety hazard are currently unknown. To make this problem more complex, preliminary studies indicate trainees? involvement is a risk factor, yet the TI skill is considered as essential for all pediatricians who provide neonatal care. Surprisingly, there has been limited interventions to improve the safety of this hazardous TI procedure. The primary objectives of this project are 1) to describe and quantify the safety outcomes in neonatal TIs by expanding National Emergency Airway Registry for Neonates: NEAR4NEOs registry across 12 academic NICUs. This will also identify modifiable patient, provider, and practice factors affecting neonatal TI safety; and 2) to decrease adverse TI associated events and severe desaturations (drop in oxygen saturation by 20% from baseline) by implementing a novel, video-laryngoscope (VL) assisted expert coaching with explicit standardized language as an educational intervention across 10 academic NICUs with pediatric residency and neonatology fellowship. The timing of intervention will be randomly staggered so that we will be able to adjust for confounding by a secular trend. Innovative remote VL coaching simulation will be utilized to train site leaders and ensure neonatology attending physicians are trained at a mastery level. This project is significant for two reasons. First, this will be the first multi-center effort to describe and quantify the adverse events associated with neonatal TI. The investigators developed and implemented the NEAR4NEOs database have a strong track record of successful TI registry development in older children. We will further leverage the expertise and infrastructure from this successfully expanding registry across 36 pediatric ICUs. Second, this project evaluates the intervention using VL technology while assuring appropriate training for pediatric trainees and frontline providers. Currently, pediatric trainees are expected to perform neonatal TIs using traditional direct laryngoscopy technique. While supporting this training setting, using VL coaching will further provide opportunities to make the procedure safer. This project is innovative in the way VL is used as an educational technology, and the proposed remote education for site neonatologists to master coaching skills using explicit, standard language and cognitive aids. This R21 will establish the infrastructure and pilot data to support future R01 evaluations of evidence-based neonatal TI quality improvement interventions. The long term goal is to develop an ongoing national collaborative network to benchmark and implement a series of neonatal TI safety interventions with an innovative strategy across diverse NICUs and delivery rooms for continuous improvement in safety and quality of neonatal care.